Nearly two-thirds of emergency medicine physicians work in urban communities, and the staffing mix in rural counties reflects an emergency physician shortage in those areas of the country.
Emergency department staffing patterns have a gaping urban-rural divide, new research shows.
In 2014 Medicare data, the distribution of emergency medicine physicians is strongly skewed toward urban areas. The researchers found urban counties had a much higher proportion of emergency physicians—63.9% compared to 44.8% in rural counties.
The shortage of emergency physicians in rural areas is severe, says M. Kennedy Hall, MD, MHS, lead author of the research and an emergency department physician at Harborview Medical Center in Seattle.
"Rural area patients are now considered a disparity population, and rural areas are faced with an ongoing problem of insufficient numbers of emergency medicine-specialty physicians to staff their emergency departments," Hall told HealthLeaders last week.
Hall says earlier research has shown that rural areas have fewer incentives and more barriers compared to urban areas for ER physicians seeking employment. That research found several factors influence job location choice:
Lifestyle
Access to amenities and recreation
ER volume and acuity
Family and spouse considerations
Access to specialists
Location of residency programs, which are mostly set in urban locations
In rural areas, research published in 2013 indicates there also are budgetary and strategic factors at play in the employment of ER physicians. Some hospital executives reported that low ER patient volume and acuity did not justify hiring emergency medicine specialists. The executives also reported satisfaction with the care provided by their non-emergency medicine physicians and advanced practice providers.
In rural areas, cost considerations discourage the hiring of emergency medicine physicians, Hall says.
"A provider mix with preferential hiring of non-emergency medicine physicians and advance practice providers at lower salaries can form a larger staff than a few highly paid emergency medicine-specialty physicians, which can in turn provide care to larger rural areas."
ER Staffing Mix Reflection of Urban-Rural Gap
Hall and his team found that rural areas have a much larger proportion of nonemergency physicians and advanced practice providers than urban areas.
In the study, which was published by Annals of Emergency Medicine, urban counties accounted for 50,157 emergency medicine clinicians, with ER physicians dominating the mix:
Emergency physicians, 63.9%
Non-emergency physicians such as family practice doctors, 12.0%
Advanced practice providers such as nurse practitioners and physician assistants, 24.1%
Rural counties accounted for 8,408 emergency medicine clinicians, with non-emergency physicians and advanced practice providers outnumbering emergency medicine physicians:
Emergency physicians, 44.8%
Non-emergency physicians, 28.3%
Advanced practice providers, 26.8%
In addition to lower staffing costs and easing the ER physician shortage, Hall says non-emergency physicians and advanced practice providers are a good fit at rural ERs with expanded care models.
He says non-ER physician providers can be essential caregivers in an integrated emergency medicine and primary care model.
"As emergency departments increasingly serve as health safety nets in rural areas—becoming both primary sources for hospital admission and hubs for unplanned acute care—a mixed ER staff of emergency physicians, non-emergency physicians, and advanced practice providers may be able to better collaborate on care coordination."
Under this model, non-emergency physicians and advanced practice providers give more comprehensive care than traditional ER models, says Hall, an assistant professor at the University of Washington School of Medicine in Seattle.
"The varied and usually primary care-centered training and skills of non-emergency medicine physicians and advanced practice providers serve as a valuable asset in addressing patients' health over a longer term than typically considered in traditional ER models."
Hall says hospital executives should consider four factors when deciding ER staffing targets:
Whether patient volume is large enough to generate a cost-neutral or cost-saving employment of emergency medicine physicians
Whether budget considerations dictate the hiring of non-emergency physician staff to serve a coverage area adequately
Whether the care model favors emergency physicians or a more balanced mix of healthcare providers
Whether there is the capability to provide training and experience for non-ER physicians who lack emergency medicine board certification
A North Carolina health system finds racial disparity in pneumonia patient readmission rates, identifies causes of problem, launches interventions, and eliminates gap.
In less than two years, Novant Health eliminated disproportionately higher hospital readmission rates for African-American pneumonia patients, who had readmission rates 4% higher than Caucasian patients.
The impetus for the initiative came in April 2016, when Novant President and CEO Carl Armato signed the American Hospital Association's #123for Equity Campaign pledge.
"That's really what jumpstarted this project," says Regina Fambrough, program manager for diversity and inclusion.
After signing the equity pledge, one of the first steps taken to address diversity gaps at Novant was an examination of readmissions data at the health system, which features 11 acute care hospitals.
In the analysis, readmissions were segmented by race, ethnicity, language, gender, age, and payer source.
"What we found was there was a disparity, and it could continue to get worse. The readmission rates for African-American pneumonia patients were 4% higher than for the Caucasian population," says Tanya Blackmon, executive vice president and chief diversity and inclusion officer.
Novant closed the gap last year:
In the third quarter of 2017, the readmission rate disparity was cut in half to 2%
In the fourth quarter of 2017, readmission rates for pneumonia showed no disparity
Finding Disparity Causes
In May 2016, the Winston-Salem-based health system formed the Pneumonia Readmissions Team to study the source of the disparity and to launch interventions aimed at closing the readmissions gap.
The Pneumonia Readmissions Team, which includes Blackmon and Fambrough, is an interdisciplinary panel that meets monthly.
The panel includes a hospitalist physician, the health system's transcultural health manager, the director of case management, a care coordination representative, nursing, pharmacy, a pulmonary navigator, and a data and analytics representative.
The team's data analysis, which included 100 comprehensive medical record reviews, revealed two primary causes of the African-American pneumonia readmissions gap:
For patients who were readmitted, there was often fewer case management assessments compared to other patients and few people to provide home care.
Care coordinator calls to African-American pneumonia patients were problematic. For example, when the transcultural health manager called these patients, Blackmon said she found they didn't realize the calls were from a care coordinator.
Novant has launched several initiatives to close the African-American pneumonia readmissions gap, such as:
Collaboration between case management and electronic health record report writers to redesign patient lists to encourage assessments at discharge, which has helped boost case management assessments 22%
Warm handoff: Discharge nurses tell the patient that the care coordination team will be following up by phone and to expect a call
Pulmonary navigators, who were hired to work closely with pneumonia and COPD patients, organize timely patient referrals to the care coordination team for follow-up postdischarge
In 2017, Novant launched new scheduling for patient follow-up visits, with follow-up visits set before hospital discharge. The new scheduling drove a 12% improvement in African-American pneumonia patients receiving a follow-up visit within seven days of discharge, and there was a 25% increase in patients keeping appointments.
Blackmon says Novant expects to have return on investment numbers for the initiative later this year, but says the effort is generating cost savings.
"We are all in agreement that there are avoidable costs here—when you are readmitting a patient, you may not get reimbursed for the readmission," she says.
In February, the Centers for Medicare & Medicaid Services recognized Novant's pneumonia disparity work with the inaugural Health Equity Award. Kaiser Permanente also received the award, which was presented in Baltimore.
A New Jersey health system launches several efforts to prevent and contain workplace violence against healthcare workers.
Workplace violence is a widespread problem within the healthcare setting that must be prevented for the safety of clinicians and patients.
That's why RWJBarnabas Health is taking a stand against workplace violence at its hospitals and clinics.
Over the past year, West Orange, New Jersey–based RWJBarnabas Health, an academic integrated healthcare system, has launched or enhanced efforts to curb workplace violence.
"Nurses, nursing assistants, and security guards are more likely to encounter violent behavior, but it is not limited to them. You can find violent incidents in all areas of a health system's facilities," says Nancy Holecek, RN, MHA, MAS, senior vice president and CNO of RWJBarnabas Health's Northern New Jersey Region.
Data showing the impact of the health system's violence prevention efforts is not available yet, but RWJBarnabas is currently collecting data to gauge the impact, monitor violence trends, and plan additional prevention measures, Holecek says.
“There are several indicators that we monitor related to our workplace violence efforts, including the number of reported incidences, employee health referrals, and medical claims data,” she says.
Here are five things that RWJBarnabas is doing to thwart workplace violence:
Created facility safety assessments
Facility safety assessments seek to ensure buildings are as safe as possible, Holecek says.
"We have been looking at our technology, looking at our visitor access system, and looking at our security workforce to ensure that we have the most updated technology and that we have our entrances covered and locked down at the appropriate time," she says.
A major facility challenge is aligning safety and service, she says. "We have to always make sure that we balance the security piece with open access for anyone who needs our services."
Instituted quick reporting technology for violent incidents
RWJBarnabas focused on ease of reporting largely because workplace violence incidents are underreported, Holecek says.
"If it's an event that results in a serious injury, then it gets reported. If it's something minor or a threat, unless staff members truly feel they are in danger, they generally treat the incident as part of the symptoms or disease that a patient is presenting," she says.
The health system has adopted reporting technology that allows staff members to click on a computer desktop icon and quickly file reports on workplace violence, she says.
Eased reporting has created a data opportunity, she says. “We have seen an increase in reported events, which was to be expected. The trending of this data related to number, severity, location, and person—patient, visitor or other—will allow us to better track, respond, and strategize our efforts.”
Raised awareness among staff
Raising awareness about workplace violence boosts safety and increases the likelihood of reporting, Holecek says.
"Oftentimes, [violent behavior] is something a patient can't control [because of] dementia or a behavioral health issue. Our staff understand this and make excuses for it. The problem with that is we can't collect data and we can't intervene; so, we are encouraging our staff to report," she says.
Enhanced training
RWJBarnabas is improving its Behavioral Emergency Safety Training (BEST) with the help of a consultant.
"The focus is to de-escalate the behavior—not to pin the person against a wall. This has been very successful. It works a large percentage of the time," Holecek says of BEST.
The consultant is adding a new layer to the BEST training—instructing staff about duty to warn, duty to act, and duty to respond.
"The consultant is training trainers who will go out to work with our security workforce, behavioral health workforce, and emergency workforce, and then expand to make sure all of our employees are trained," she says.
Added violent incidents to daily debriefings at each of RWJBarnabas' 11 hospitals
Addressing incidents of workplace violence has become part of a larger high-reliability initiative at RWJBarnabas.
The initiative includes 15-minute leadership huddles in the morning at every RWJBarnabas hospital to review facilitywide issues from the previous 24 hours. Workplace violence incidents are among the topics discussed.
The CEO usually leads the morning huddle, with about 45 participants ranging from the C-suite to the department director ranks.
"This informs the entire senior team and department heads so they know what has transpired. It helps us stay abreast of any incidents of workplace violence that may have occurred," Holecek says.
Another workplace prevention effort
In addition to those initiatives, the health system formed a steering committee to lead workplace violence prevention efforts.
The Workplace Disruption Prevention Steering Committee oversees the office of emergency management, security, and workplace violence.
The steering committee is an interdisciplinary group with representatives from compliance, emergency management, HR, legal, nursing, physicians, IT, and security.
"On the Workplace Violence Committee, we have the same steering committee members, but we also have an emergency department physician and a nurse from behavioral health. We wanted to make sure there were people who experience these kinds of issues day in and day out," she says.
Guidance to prevent workplace violence
Recent guidance issued by The Joint Commission features seven recommendations to prevent workplace violence that could help healthcare organizations prevent violent encounters.
Holecek says she and her colleagues are examining the workplace violence report released by The Joint Commission.
The report could prompt more workplace violence initiatives at RWJBarnabas, she says.
New research provides guidance for implementing clinician dress codes at health systems, hospitals, and physician practices.
Physician attire impacts patient satisfaction, with preferences for clinician couture varying by care setting and patient attributes such as age, researchers have found.
"Our work shows that patients care. So, for institutions that don't have a dress code or formal policy for attire, it might be time to consider one," article co-author Vineet Chopra, MD, MSc, of the University of Michigan Medical School and VA Ann Arbor Healthcare System told Healthleaders this week.
Out of 4062 patients surveyed, 53% said physician attire was important to them. The research was published in BMJ Open.
Overall, patients preferred formal attire with a white coat, ranking that ensemble an 8.1 on a scale of 1 to 10. "Our work shows white coats matter the most. I think this is an important takeaway for institutions," Chopra says.
The researchers found that preference for physician attire is influenced by patient attributes and care settings:
Female patients preferred scrubs with white coats in emergency room and hospital setting compared to men (41% vs. 31%)
In hospitals, patients 65 and older preferred formal attire with white coats more than younger patients (44% vs. 36%)
Younger patients preferred scrubs and white coats over formal attire (28% vs. 21%)
Patients with a college degree preferred formal attire and white coat for family physicians more than patients without a degree (48% vs. 42%)
Patients preferred formal attire with white coat for primary care (44%) and hospital physicians (39%), but scrubs were rated highest for ER physicians (40%) and surgeons (42%)
Patients also had regional differences in their preference for physician attire.
"While formal attire and white coats were preferred across all regions, 50% of respondents in the West and 51% in the South selected this as their preferred option compared with 38% and 40% in the Northeast and Midwest, respectively," the researchers wrote.
The findings on patient preference variation for physician attire indicate that healthcare organizations should take a nuanced approach to dress codes, Chopra says.
"Preferences may vary based on location and context. Institutions may want to consider examining specific areas to understand whether or not more defined dress codes might be indicated."
The research is consistent with common perceptions about professionals, the researchers wrote.
"These findings make intuitive sense: Patients often have notions of how a 'professional' should dress and are more likely to respond positively to those that meet these stereotypes. Strategies targeting physician dress may therefore enhance trust and satisfaction."
The research is based on a questionnaire that included photos of a male and a female physician in seven different sets of attire. Patients were asked to rate the physicians in several clinical settings. The rating system had five domains: knowledgeable, trustworthy, caring, approachable, and comfortable.
Formal attire with white coat scored highest for all five domains.
The research includes several other key data points:
In the overall rankings, scrubs with a white coat ranked second to formal attire with white coat. Formal attire without a white coat ranked third.
In ER and surgery settings, scrubs alone were preferred by 34% of patients followed by scrubs with white coats (23%)
36% of patients said physician attire impacted satisfaction with their care
55% of respondents said doctors should wear a white coat during office visits with patients
Matching physician attire with patient expectations can improve patient experience, the researchers wrote.
"Providers engaged in care of elderly patients … may consider donning formal attire more so than surgeons or emergency room physicians where scrubs may be more important. Similarly, hospitals in Southern regions of the USA may wish to endorse formal attire and white coats."
The research has policy implications, they wrote.
"Patients appear to care about attire and may expect to see their doctor in certain ways. Hospitals, clinics, emergency departments and ambulatory surgical centers should consider using these data to set dress codes for physicians providing care in these settings."
Several factors are making specialists hot commodities, including the aging population, lifestyle-related diseases such as obesity, and a shortage of psychiatrists, healthcare staffing agency says.
In an annual healthcare staffing survey, family physicians rank as the top requested recruiting assignment for the 12th year in a row, but demand for specialists is trending upward.
Recruitment activity is shifting toward medical specialists, according to the 2018 Review of Physician and Advanced Practitioner Recruiting Incentives. The survey, published by Dallas-based Merritt Hawkins, found 74% of search assignments were for specialists, up from 67% three years ago.
In physician compensation, the survey found invasive cardiologists had the highest average starting salaries at $590,000. Orthopedic surgeons were second at $533,000.
Three factors are driving increased demand for medical specialists, starting with the country's aging population, says Travis Singleton, Merritt Hawkins executive vice president.
"It is specialists such as cardiologists, orthopedic surgeons, pulmonologists and others who care for the ailing organs, bones, and brains of our fastest growing patient cohort—seniors, who are disproportionate users of care."
Lifestyle-related disease and behavioral health are also increasing demand for specialists, he says. "Rising rates of obesity, diabetes, drug abuse, and mental health problems are creating a sicker patient population, the kind commonly treated by specialists."
The third factor boosting demand for specialists is the cyclical nature of the physician employment market, Singleton says.
"Hospitals, medical groups, and other healthcare facilities have emphasized primary care recruitment in recent years, and now they need specialists to whom their primary care doctors can refer."
The survey was conducted from April 2017 to March 2018, and it is based on a sample of 3,045 clinician search assignments. In addition to the medical specialist and top compensation findings, the survey has six other key points:
Reflecting an ongoing shortage, psychiatrists were second on the list of Merritt Hawkins' most requested recruiting assignments for the third year in a row.
Demand for nurse practitioners (NPs) and physician assistants (PAs) is rising. Merritt Hawkins conducted more search assignments for NPs and PAs than in any other 12-month period tracked by the company.
While the tying of physician compensation to value is spreading, value was linked to only 8% of compensation in the survey.
In record highs for the survey, the average physician signing bonus was $33,707, the average starting salary for family physicians was $241,000, and the average starting salary for a nurse practitioner was $129,000.
Employment remains the dominant physician staffing model, with more than 90% of Merritt Hawkins' search assignments set at employed practice settings and less than 10% at independent practices.
In a record high for the survey, 62% of recruiting assignments were in communities of 100,000 or more. The survey authors linked the trend to the rising demand for medical specialists, who tend to practice in large communities.
The shortage of psychiatrists has been worsening for years, Singleton says.
"In 2005, psychiatry was No. 13 in our list of most requested types of searches. Five years ago, in 2013, psychiatry was No. 4 on the list. For the last three years, it has been No. 2, trailing only family medicine."
Psychiatrists are a dire pain point in the nation's clinician shortage, he says. "We judge the shortage in psychiatry to be more severe than any other specialty we recruit."
There is little relief in sight, Singleton says. "Though there has been increased interest in psychiatry among medical graduates selecting residency programs recently, our ability to train more psychiatrists remains limited because residency positions are limited."
A physician group repositioned itself on firmer ground by implementing a plan that not only helped patients, but its bottom line.
Clinical care and access initiatives played key roles in a $56 million year-over-year operational budget turnaround at Atrius Health in Massachusetts.
The Newton-based physician group posted a $31.6 million operating loss in 2016 and a $24.4 million surplus last year, according to the President and CEO Steven Strongwater, MD, at Atrius Health.
Reasons for the weak financial performance at Atrius in 2016 included unsustainable staffing costs, he says.
There were three core elements in Atrius' turnaround plan: patient volume growth, cost control, and medical expense management.
1. Increasing patient volume
Increasing access to care was a crucial component of increasing patient volume, says Strongwater. "Our core approach is to improve access. We try to make ourselves available when and how our patients need us."
To supplement its primary care and urgent care clinics, Atrius has recently launched several telemedicine services, including dermatology, behavioral health, urgent care, and developmental pediatrics. At least 10,000 patients have used the telemedicine dermatology service.
"We like telehealth," Strongwater says. "We believe it should be incorporated into usual care within our practices as opposed to the big national firms like American Well and Teledoc. They are not your doctor. They are not accessing your electronic medical record. When you have a telehealth visit with us, we are in your record, we know who you are, we have access to prior treatment."
Atrius, which features 825 physicians practicing in 32 locations, plans to continue expanding telemedicine services. The next service set for launch is OB/GYN care for routine pregnancies.
There is significant potential for more telemedicine offerings at Atrius, he says. "Whenever patients can avoid an in-office encounter and get treated in the comfort of their own home, those are the ideal opportunities to roll out telemedicine. Almost every specialty has an application for telemedicine."
2. Controlling operational costs
Expense management efforts at Atrius included layoffs totaling 188 FTEs, supply chain cost cutting, and controlling site of service.
"It is more expensive to be treated in an inpatient unit than an ambulatory unit. We moved thousands of patients who would have otherwise been in a hospital unnecessarily to ambulatory units," Strongwater says.
Ambulatory surgery has been a prime area to generate site-of-care savings, he says. "We moved surgeries that were going to be done in hospitals to ambulatory surgery centers. We set up a program using our VNA Care in the home."
Atrius also has limited hospitalizations by bringing the hospital to the home.
"This allows us to move patients who traditionally would have been hospitalized—mostly medical patients but sometimes surgical patients—and set up a hospital in their home. We put a biometric patch on them, put telehealth in the home, and there is bidirectional video connected to a 'mission control,' " he says.
The home hospital service includes visiting nurse care.
"Our VNA goes into the home and provides care and services that are needed. We can provide pretty much everything except advanced imaging. We can provide antibiotics, we can provide fluids, we can do physical therapy and behavioral health, and we can deliver meals."
Patients are screened for home hospital suitability, Strongwater says.
"Patients have to have the right social environment at home. The patient has to be safe, there needs to be confidence that there will be electricity and other basic services, and the patient needs to be relatively intact cognitively," he says.
3. Medical expense management
Boosting population health capabilities was a primary strategy to control the medical cost trend at Atrius.
"Generally, about 5% of patients drive about 30% to 40% of healthcare spend. If you can manage those people, keep down their hospitalization rate, keep them out of skilled nursing facilities, and provide services in the home, their costs will go down. That is what we have been doing," he says.
Analytics have help boost population health at Atrius.
"We try to identify high-risk patients through risk predictors, then triage the information to the right people. It could be triaged to a VNA, a case manager, a population health manager, or a care facilitator. Then the appropriate intervention is tailored to the needs of the patient," Strongwater says.
Expansion of behavioral health services also has helped reduce medical expense at Atrius, he says.
"Behavioral health comorbid conditions increase total medical expense by two- to sevenfold. So, we have created new triage programs to get our sickest behavioral health patients seen quickly and get intensive therapy. Instead of coming in every month, we have patients come in every week."
At Atrius, behavioral health offerings are financially negative on a standalone basis, but it is money well spent, Strongwater says.
"We subsidize behavioral health—we don't break even on that service. We subsidize it because we believe it has a big impact on total cost of care. We also believe it's related to why our medical expense trends are lower than other physician groups."
To improve its behavioral health assessment capability, Atrius has adopted Patient Reported Outcome Measures.
"We are one of the earliest in Massachusetts to usePROMs in behavioral health," he says. "We tend to use PROMs more in surgical conditions like total joint replacement or back pain. In behavioral health, it's exciting. You can get a much better view of how the patients are doing by having the patients report it to you using these standardized screening tools."
Atrius has repositioned itself on firmer ground, Strongwater says. "We are better coordinating our clinical protocol across all of our sites, we are standardizing a lot of our clinical care, and we are improving access for patients."
With safety and finances on the line, effective patient identification methods include requiring adults to present a photo ID, having patients read their wristbands to confirm information, and installing patient registration kiosks.
Effective patient identification is one of the keys to ensuring quality care and avoiding financial losses at health systems, hospitals, and physician practices.
"The misidentification of patients in clinical settings has untold financial impacts for an organization in uncompensated care as well as serious patient safety consequences, such as wrong-side surgeries and even death," according to an article in the Journal of AHIMA's June edition.
A Ponemon Institute survey of 503 nurses, physicians, and health IT workers, the "2016 National Patient Misidentification Report," details some of the negative consequences associated with patient identification failures:
86% of survey respondents said they had witnessed or were aware of a medical error caused by patient misidentification
Survey respondents said 35% of claim denials are the result of inaccurate patient identification or faulty patient information
On average, claim denials linked to inaccurate patient identification or faulty patient information cost $1.2 million annually
The Journal of AHIMA article, "Tips for Trusting Identity in the Era of Cybercrime and Fraud," highlights six best practices for patient identification:
Two-factor authentication is the industry standard for verifying patient identity such as name and date of birth, but using three or four factors such as adding home address is more effective.
Asking patients to verbally state their authentication factors is more effective than having registrars ask "yes" or "no" questions to verify information.
Adult patients should be required to present a driver's license or some other form of photo ID as part of the identification process.
If possible, patients should read their wristbands to confirm the accuracy of their registration. Patients can also be asked to confirm the accuracy of their information on the registrar's computer screen.
Healthcare organizations should consider taking photos of patients and including those images in medical records. Benefits of photographing patients include deterring medical ID fraud and helping clinicians to see that they are treating the right patient.
Patient registration kiosks have several benefits: they can take a patient's photo, they can match images of a patient to a photo ID or photos in a database, and they can require patients to verify their demographic information.
While most physicians surveyed recently saw a need for chronic care management services, barriers to adoption include patient skepticism, doctor unfamiliarity with Medicare reimbursement, and physician concern over complicated coding.
Most primary care physicians would like to offer chronic care management (CCM) services to their Medicare-eligible patients, but there are several barriers to adoption, a recent survey found.
Chronic conditions include hypertension, cancer, arthritis, and diabetes. These kinds of conditions are not only associated with long-term impairment, but also 71% of healthcare costs, according to the Quest Diagnostics survey, "Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multiple Chronic Conditions."
"Three in four Americans over the age of 65 have two or more
chronic health conditions. These patients are generally sicker, more likely to use hospitals and emergency rooms, have greater limitations
in their daily living, and experience accelerated decline in their quality of life," the survey authors wrote.
CCM services are designed to guide and support patients who have multiple chronic conditions (MCCs). CCM services include electronic and phone consultation, medication management, and 24-hour access to care providers. Medicare Part B pays for CCM, with average reimbursement ranging from $42 to $62.
Physicians see a need for CCM, according to the survey, which polled 801 primary care physicians and patients over 65 with MCCs:
93% of the physicians wished they had help ensuring MCC patients were adhering to their care plans
92% reported MCC patients struggled with adhering to their care plans
85% said they lacked the time to provide adequate care for MCC patients
Only 9% said their MCC patients were getting the care and attention they needed
There are several barriers to CCM adoption, the survey found:
MCC patients surveyed said they were largely satisfied with the care provided at their primary care physician office, with 92% reporting they were getting all the attention they needed at their PCP
Only 51% of physicians surveyed knew that the Centers for Medicare & Medicaid Services pay separately for CCM under the Physicians Fee Schedule for qualified patients with MCCs
77% of the physicians said they had not implemented CCM, with 43% citing complicated coding, 37% citing burdensome paperwork, and 25% citing low Medicare reimbursement
3 Strategies
There are three strategies to overcome the barriers to CCM adoption, according to the survey:
To address the perception of CCM complexity among primary care physicians, adoption solutions should include simplifying the process such as providing coding expertise.
PCPs can make convincing arguments to patients to use CCM services, including medication adherence and reassuring patients that CCM has only modest copays under Medicare.
Physicians can explain to patients that CCM helps address health concerns before they become major medical problems. In the survey, the Number One worry among patients was "getting another medical condition" (43%).
A doctor offers four recommendations to curb harassment and assault against healthcare providers.
A Massachusetts-based physician is calling on the healthcare community to develop more effective responses to patients who engage in harassment or other negative interactions.
"There is only a relatively small body of literature on harassment in medicine, and it tends to focus on acts committed by colleagues and superiors rather than by patients or clients," Charlotte Grinberg, MD, wrote in an article for Health Affairs.
"Clearly, patients can also be offenders. This should not be ignored."
Grinberg, resident physician at Mount Auburn Hospital in Cambridge, Massachusetts, shares three incidents from her past to illustrate potentially dangerous workplace environments:
When she was a sophomore in college, Grinberg did GED tutoring at a correctional facility. After an inmate masturbated during a tutoring session, she reported the incident to a guard, who said, "These things sometimes happen."
As a second-year medical student, Grinberg volunteered at a homeless shelter, where she connected residents with community resources. After a resident with whom she had worked was charged with raping a store clerk, it changed her: "I kept the visits brief. I avoided physical contact. I didn't give out my phone number or offer to call patients on other days of the week to follow up."
In her third year of medical school, an end-stage liver disease inpatient tried to pull Grinberg into his bed while making sexually suggestive comments. "I wondered if this was somehow my fault, and how I could ever provide care to Steven again," she wrote.
Although all three incidents were reported, only the inpatient encounter was reviewed. "I started feeling little less alone and a little less responsible," Grinberg wrote.
There are rarely easy answers when patients harass or assault their caregivers, she wrote, "Sometimes, these assaults are by-products of diseases such as psychosis and dementia. We wouldn't want to react to someone who lashes out because of dementia in the same way we react to someone who is lashing out for reasons within their control."
She offers four recommendations to curb harassment and assault in healthcare settings:
There is widespread promotion of safety incident reporting. Similarly, healthcare organizations should foster workplace environments where it is safe to report harassment and other negative interactions with patients.
Raise awareness among healthcare staff members about the potential for patients to engage in harassment and assault, and explain the benefits of reporting incidents.
Form a culture that allows caregivers to discuss incidents with patients directly. "Our duty is to serve all patients, no matter what sort of people they are. But this does not mean we need to accept or ignore abuse," Grinberg wrote.
Carefully examine existing interventions to guide the creation of new policies. "Such policies will help doctors like me in the future and ensure that although these things do sometimes happen, there is something we can do about them," she wrote.
A children's hospital has more than doubled its number of submitted incident reports, overcoming challenges such as employees' fear of retaliation for reporting.
Over a three-year period, Children's National Health System in Washington, D.C., more than doubled the number of incident reports filed by employees, creating opportunities to improve quality and safety for patients.
"If we don't know what's going on in our organization, we can't improve," says Rahul Shah, MD, MBA, vice president, chief quality and safety officer. "Any organization that fears increased reporting is missing the boat."
A research study about the incident report initiative was recently published in Pediatric Quality & Safety. Data in the study quantify the achievement at Children's National as follows:
2014 safety event reports totaled 4,668
2017 safety event reports totaled 10,971
Report submission time was decreased by nearly 30%
Number of submitting departments increased by 94%
Anonymous reporting decreased 69%
Overcoming 3 Challenges
Before Children's National, which features the Sheikh Zayed Campus for Advanced Children's Medicine with 316 inpatient beds, doubled their incident report numbers, they identified three incident report challenges that it needed to work through to achieve the goal of improving quality and safety for its patients.
"What we realized is we had to improve technology, we had to change the culture so it was safe to report, and we had to show reporting made a difference," Shah says.
Improve technology
To ease reporting through improved technology, Children's National rolled out mobile reporting with an app-based platform and optimized the platform with specific reporting categories such as falls and compliance. In another effort to save time, the number of mandatory fields in the reporting templates was reduced.
The technology upgrades have made it easier to submit incident reports, helping to cut submission time from 12 minutes to 7 minutes, Shah says. "That's a big 5-minute time saving for a clinical nurse or respiratory therapist who is busy."
Change organizational culture
Creating a culture where employees feel safe to submit incident reports is a significant challenge, Shah says.
The decrease in anonymous reporting reflects well on efforts to assuage fear of making a report, he says.
"People will say they are making an anonymous report out of fear and to avoid retaliation. We worked on that aspect of our culture. We believe the decrease in anonymous reporting is a surrogate for our culture improving," he says.
Shah continues, "We adopted the concept of a just culture, where everyone in the organization gets treated in the same way. We partnered with human resources to ensure that we embodied, espoused, and showed employees that we had a just culture."
Children's National also adopted a positive philosophy for incident reports, he says.
"Many organizations call these documents incident reports. We call them safety reports, which takes away a pejorative and negative connotation. The whole initiative was called 10,000 Good Catches and when people make good catches, we celebrate them," Shah says.
Other efforts to gain trust and reporting participation from Children's National staff have included one-on-one outreach, naming a monthly Reducing Harm Hero, and the awarding of "Zero in on Zero Harm" pins.
Staff members also know their incident reports are being reviewed at a senior executive level, Shah says. "I read every incident report in the organization. I made that pledge about three-and-a-half years ago, when we had 4,000 incident reports. I still stand by that pledge when we have 11,000 incident reports."
One of Shah's subordinates also reads all incident reports, as does the chief risk officer and a deputy. "Everyone in the organization knows that when they file an incident report, at least four leaders will look at it," he says.
Show reporting makes a difference
Showing employees that their incident reports make a difference also can be challenging. But Shah cites two examples of incident reports that led to significant quality or safety improvements.
Example 1: Code Simulation Program
In one instance, a patient required resuscitation at a Children's National satellite clinic. "That is pretty much all the incident report said," Shah says.
Based mainly on the incident report, Children's National decided to spread its emergency code simulation program from the main hospital to the satellite clinics. The simulation program focuses on cardiac arrest and other resuscitation emergencies. Children's National subject-matter experts developed the program, which is also staffed internally.
Shah believes the new code training has saved at least one life.
"Six months later, a child was having a seizure in one of our satellite clinics, turned blue, and needed resuscitation. It took EMS about 10 minutes to get to the clinic. By the time EMS arrived, the child was intubated, stabilized, and properly coded."
Example 2: Safe Restraint Techniques
Another example of incident report impact involves behavioral health patients.
"One area that hospitals all over the country struggle with is behavioral health and violence in those patients. We had a safety event report regarding violence toward staff from behavioral health patients," Shah says.
Several safety changes were adopted, he says. "From that safety event report, we asked, 'How can we keep our staff safe?' Now, we have training. We have Kevlar sleeves for our employees to use. We have different techniques for restraining patients."
National Children's incident report initiative has far exceeded Shah's expectations.
"To see those 11,000 reports come in, they are almost changing in front of my eyes. I'm seeing them getting rich with information and opportunities for improvement. People are trusting me and the organization, and they know we have their back," Shah says.
